Prior approval and quantity limitations
Select the plan for which you would like to review prior approval and quantity limitation information:
Blue Medicare HMO, Blue Medicare PPO and Blue Medicare Rx
Prior authorization and nonformulary requests
Prior authorization and nonformulary requests require members to meet certain clinical criteria prior to a drug being covered.
For prior authorization and nonformulary requests, the member or the member's prescribing physician may contact Blue Medicare HMO, Blue Medicare PPO and Blue Medicare Rx. A physician's supporting statement is required for all requests before the prescription can be approved for payment. Physicians may contact the plan by calling Blue Medicare HMO or Blue Medicare PPO at 1-877-494-7647 or Blue Medicare Rx at 1-888-298-7552 or using the applicable fax request form (see below) to request an exception. Please see the member's formulary for detailed information regarding covered drugs and drugs requiring prior approval. Download and submit the following forms to request prior approval for a nonformulary drug request.
Should list drug alternatives tried by member for the same condition and the clinical reason these drugs have not been as effective as the drug being requested.
Drugs that require prior approval
Drugs that can be covered under Part B, Blue Medicare HMO, Blue Medicare PPO and Blue Medicare Rx. Please see the member's formulary for a list of drugs that require prior authorization. Drugs that are currently authorized by law as covered under Part B will remain covered under Part B and should be billed to the Part B payer as before. For information about and a listing of drugs covered under Part B, visit the Cigna Government Services Web Site. This site includes access to DME MAC Jurisdiction C Local Coverage Determinations. You may also visit the CMS Web site for additional information regarding Part B and Part D coverage.
Below is a list of medications/drug classes that can be covered under Part B, Blue Medicare HMO, Blue Medicare PPO and Blue Medicare Rx. Coverage is dependent upon indication and/or administration:
If these medications are not eligible for coverage under Part B, they will be covered under Part D with prior approval by the plan. Examples of drugs always covered under Part B:
The Quantity Limitations program sets quantity limits on a small number of medications. Blue Medicare HMO, Blue Medicare PPO and Blue Medicare Rx will cover the drug up to the designated quantity. If the prescribing doctor feels it is medically necessary to exceed the set limit, they must get prior approval before the higher quantity can be covered. Physicians can call Blue Medicare HMO at 1-888-310-4110, Blue Medicare PPO at 1-877-494-7647, or Blue Medicare Rx at 1-888-247-4142. After normal business hours messages can be left on the Part D After Hours Exception voice mail.
Quantity Limitations are designed to identify the excessive use of drugs which may be dangerous in large quantities and to highlight the potential need for a different type of treatment.
For patients who may require dosages in excess of the quantity limit (QL), please download and submit the appropriate fax request form listed below.
1 * All services are subject to the allowed amount charge. When using out-of-network providers, any amount charged over the allowed amount may be your responsibility.
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